Prisoners with mental illness continue to struggle for recognition and services in a changing behavioral health care system at the Colorado Department of Corrections (CDOC), according to a recent report by the Office of the State Auditor.

Auditors found that prisoners with mental illness are not consistently diagnosed or tracked through the system, sometimes resulting in inappropriate (or even illegal) solitary confinement or disciplinary segregation.

At a Dec. 6 Legislative Audit Committee hearing, CDOC leaders agreed with many of the recommendations in the report, but also defended recent improvements.

In a statement, the department said “many of the audit findings can be attributed to acclimation as we seek to create, deliver and implement innovative and progressive new programs.”

CDOC also blamed an antiquated computer system, which will be replaced in two to four years, and staff shortages. In the 2015 and 2016 fiscal years, 20 percent of the positions in the mental health program were vacant.

Health disparities are perhaps nowhere more stark than in prisons. Incarcerated people suffer higher rates of tuberculosis, HIV/AIDS and Hepatitis C, according to the Center for Prisoner Health and Human Rights at Brown University. Diabetes, hypertension, and asthma are also more prevalent among prison populations, and some research has found that prison inmates fail to get treatment for chronic physical conditions while incarcerated.

In 2014, 27 percent of males and 72 percent of females committed to the Colorado prison system had moderate to severe medical needs—far outpacing such rates in the general population.

Racial disparities are also profound between incarcerated people and the rest of Colorado. Compared to white adults, black adults were six times more likely to be in a Colorado jail or prison in 2014, and Latino adults were nearly one-and-a-half times more likely, according to an analysis by Rocky Mountain PBS News.

Prisons concentrate people with mental illness. Of the 17,977 offenders incarcerated in Colorado prisons as of the end of 2015, auditors found 43 percent had a psychiatric diagnosis and 74 percent needed substance abuse treatment, according to the recent audit report.

“I’ve accepted the fact that I run the biggest mental health institution in the state of Colorado,” CDOC Executive Director Rick Raemisch said at the recent legislative hearing.

The reforms only related to prisons, not jails where people are held before trial. Colorado lawmakers banned long-term solitary confinement for prison inmates with serious mental illness, except in the most extreme circumstances, in Senate Bill 64 in 2014.

Auditors found violations in 2014 and 2015 despite the new law, including:

Three inmates with serious mental illness were placed in long-term solitary confinement—spending 22 hours or more a day alone in a cell—because of problems coding prisoners with mental illness in the computer system.

Six offenders were found to have mental illness while in confinement and were not removed within 30 days, in violation of policy.

36 inmates were kept in short-term disciplinary segregation longer than the permitted 60 days. They were in segregation for an average of 84 days, and one as long as 236 days.

Additionally, prison staff did not conduct mental health reviews of prisoners before or during their stay in isolation.

Solitary confinement has been shown to exacerbate or create psychiatric illness, leading to delirium, obsessive ruminations, and self-mutilation or suicidal ideation, among other problems. Colorado has the lowest rate of solitary confinement in the nation, according to an analysis of the state’s prison reforms by watchdog organization Solitary Watch.

The residential treatment program for inmates with mental illness is supposed to offer 20 hours per week of time in activities out of cells, including 10 hours of therapeutic time. Auditors found that the department could not track how much out-of-cell time was offered to inmates, but what data existed showed 38 percent of prisoners were not offered 10 hours a week of therapeutic time. When it was offered, inmates refused the therapeutic programming 57 percent of the time.

Renae Jordan, CDOC director of clinical and correctional services, told legislators at the hearing that the department agreed with auditors’ recommendations and has already started implementing additional reforms since the auditors conducted their review.

Inappropriate confinements are an ongoing problem, American Civil Liberties Union (ACLU) of Colorado Staff Attorney Rebecca Wallace said, although the group is “confident” that CDOC does not intend to hold prisoners with mental illness in solitary confinement. Wallace called the numbers of inappropriate confinements in the audit “almost certainly undercounts.”

Raemisch said the audit came at a time when the prisons are in the midst of achieving a “vision” of reform.

“It’s still a work in progress,” Raemisch said. “We’re doing the best we can under the circumstances.”

“It’s worth noting that that has an impact throughout all the issues we looked at,” he said.

Still another finding of the auditor’s report was that CDOC lacked quantifiable targets and ways to measure the achievement of reforms that mark Colorado as a leader in prison mental health treatment.

“We understand that’s your goal and that’s your intent, but how do you know that? How do you know that that’s what’s happening?” Deputy State Auditor Monica Bowers said during an interview.

Many of the shortcomings auditors highlighted echo those raised by the ACLU of Colorado in a January 2016 letter to Raemisch. The letter praised the changes so far and recommended deploying an independent team of medical experts led by a forensic psychiatrist to evaluate the mental health program and prisoners’ diagnoses from a medical perspective. Raemisch declined that recommendation.

The recent state audit did not examine the quality of behavioral health treatment or the accuracy of prisoners’ mental health diagnoses, which leaves an unmet need for information, Wallace said.

“We have gone a long way under Rick Raemisch’s leadership, but bringing in outside clinical expertise to fully realize the promise of his reforms seems like a logical step to address some of the problems identified in the audit and in our letter,” she said.